Fundamentals of Retractors and Exposure

Abstract

Proper exposure is critical to maximizing safety and efficiency in the operating room. An operative field should be large enough to allow the operating surgeon and assistants to visualize critical anatomy and manipulate instruments comfortably and also no larger than necessary in order to minimize iatrogenic injury. There are many varieties of surgical retractors, and the ability to choose the right tool for the job can help meet the goal of keeping the view clear and the wound small.

Traditional stainless steel open surgical retractors were designed alongside the procedure they were intended to assist, with shapes that were carefully considered to meet a specific need. Effective, versatile designs have persisted to become common surgical instruments found in operating rooms worldwide. The evolution of material science, laparoscopic, and robotic procedures brought with them new instrumentation for retraction. Some minimally invasive retractors appear to be miniature versions of their open counterparts, while in some circumstances, entirely new instrumentation has been developed to meet previously nonexistent needs.

The following chapter reviews technical considerations of surgical exposure, from patient positioning to economy of motion. A useful scalar paradigm for retraction is introduced—large-scale field exposure, effective recruitment of the operative assistant, and moment-by-moment use of the surgeon’s nondominant hand. Additionally, types of surgical retractors available for open and laparoscopic surgery are described and categorized for convenient reference.